Starting the Conversation About Male Infertility

Male factors play a role in about half of all infertility cases, but male infertility often isn’t discussed with patients. A new paper led by Cleveland Clinic and featured on the cover of the December 2023 issue of Urology encourages physicians to break the silence. It shares the infertility journeys of individual patients.

In this Q&A, the paper’s senior author, Scott Lundy, MD, PhD, a Cleveland Clinic urologist and male infertility specialist, discusses why he was inspired to encourage others to speak out.

Q: Why is it important to talk about male infertility?

Dr. Lundy: There’s a lot of focus on female infertility, as there should be. But when we look at the data, male factors play a role in at least 50% of all infertility cases. I feel strongly that we need to get this message out because men often are not evaluated. Too many times, one partner goes through extensive treatment, even to the point of having in vitro fertilization, when a simple evaluation or treatment by a male infertility specialist could have made a significant impact.

Q: What are some misconceptions among providers?

Dr. Lundy: We are doing a survey on this right now, and we have found that a great number of medical professionals have vastly underestimated the prevalence of male infertility. Even more striking, they may not recognize key aspects of men’s health as risk factors. For example, many men treated with testosterone are never told that testosterone can cause infertility. And we still see young men who had chemotherapy or other cancer treatments and were never told that if they didn’t bank sperm before treatment, they may never be able to have a child.

Q: How can providers advocate for their patients about male infertility?

Dr. Lundy: I think the first thing many providers can do is simply ask if the couple is trying to conceive and if they’re struggling. If they are, assert the importance of seeing a male infertility provider or even doing something as simple as a basic semen test, which any provider can order. Normalizing the discussion around this topic is important.

Also, take time to provide emotional support, especially when a couple has experienced a miscarriage. We take time in my clinic to talk about it. We discuss that it’s a difficult event to go through and it’s OK to lean on each other as a couple, but it’s also OK to look outside for help if you’re struggling.

Q: How does infertility affect men emotionally?

Dr. Lundy: If a couple has attempted to conceive for one or two or three years and hasn’t been successful, then suddenly an activity that’s supposed to be perhaps the most pleasurable activity for our species becomes a job, and one that the couple feels like they are failing at. It’s no surprise that those men often develop erectile dysfunction or little interest in sex, not because the activity isn’t pleasurable, but because it’s a constant reminder of shortcomings. That can be another hurdle to overcome to cause a pregnancy, not to mention the stress, which is itself a risk factor for infertility.

Q: What should providers know about treating transgender patients for infertility issues?

Dr. Lundy: In our paper, a colleague spoke on this issue from the transgender perspective. If a genital exam for a male is awkward or uncomfortable, it’s even worse for someone who may feel that testicles should not be a part of their body, a source of constant struggle.

One of the assertions made in the article is that if you use the wrong pronouns for a patient in clinic and then apologize for it, you’re subconsciously placing the burden back on the patient to reassure you. I’ve done this. When I made a slip and apologized for it, I thought I was doing the right thing and didn’t realize that I was probably doing more harm than good.

How should we handle this? The first step is to set expectations by introducing yourself, providing your pronouns and then asking for the patient’s pronouns. Many providers feel that this might take too long or is different than what they’ve always done. But the simple act of asking about pronouns normalizes the issue and opens the door for further discussion. The second step is to recognize that none of us is perfect. Despite our best intentions, many of us will make mistakes and should continually strive to improve toward using inclusive language to build therapeutic trust with our patients.